Intensive Care Nursery House Staff Manual

Exchange Transfusion (ExTx)

INTRODUCTION: This procedure, used most commonly to treat severe unconjugated hyperbilirubinemia, removes the infants circulating blood and replaces it with donor blood. The amount of blood exchanged is expressed as multiples of the infants blood volume. The standard two volume ExTx uses a volume twice the infants blood volume (i.e., 170 mL/kg). The procedure is done in small increments. As the procedure progresses, relatively more of the donor blood (infused earlier) and less of the patients own blood is removed. The washout of the infants blood is a simple exponential function: Volume exchanged Patients blood removed (of patients total blood volume) (% of total blood volume) 0.5 volume 39 % 1.0 volume 63 % 2.0 volume 86 % 4.0 volume 98 % These values are for washout of the vascular compartment. However, an ExTx will remove more bilirubin than shown above. This is because unconjugated bilirubin is distributed in both the intra-vascular and extra-vascular spaces, and will move rapidly into the intra-vascualr space as the concentration decreases during the ExTx. Thus, a 2 volume ExTx will remove twice as much bilirubin as was in the circulating plasma at the start of the procedure. However, because of continued movement of bilirubin into the vascular space, the plasma bilirubin concentration at the end of the ExTx will be reduced by only of the pre-exchange level. PROCEDURE: There are several possible methods. Before proceeding with an ExTx, review the section on Intravascular Catheters (P. 25) paying particular attention to the sections on umbilical catheters. 1. Method and types of catheters: These methods are listed in decreasing order of preference (because of considerations of safety and effectiveness): A. Continuous Exchange is performed by two operators, one infuses blood and the other simultaneously withdraws it. The best method is withdrawal from an umbilical arterial catheter (UAC) and infusion into an umbilical venous catheter (UVC) with tip in IVC or right atrium. Flush withdrawal catheter with heparinized saline every 10-15 min to prevent clotting. Alternatives are: withdrawal from a peripheral arterial catheter and infusion into a central venous catheter. However, this is slow and the arterial catheter frequently clots. withdrawal from a central venous catheter and infusion into a peripheral vein. Flush the central catheter frequently to prevent clotting. B. Push-Pull Method can be done through: a single UVC with tip in IVC or right atrium. a single UAC with tip in lower aorta (below 3rd lumbar vertebra) Caution: Do not perform ExTx through a UVC if the tip is in the portal circulation. This may cause necrotizing enterocolitis by markedly decreasing bowel blood flow.
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Copyright 2004 The Regents of the University of California

Exchange Transfusion

2. Technique: With the push-pull method, use increments of 5 mL/kg. Small increments are safer and just as efficient as larger ones, provided that you clear the donor blood from the dead-space of the catheter. Do this at the end of each infusion increment by withdrawing 2 mL of blood from the catheter into the syringe and then reinfusing it. During the procedure, the operator(s) must call out the volume in and out with each infusion and withdrawal (e.g., ten in - ten out). A 3rd person must keep a written timed, running record of each infusion and withdrawal and of cumulative volumes to be sure that the volumes infused and withdrawn are equal. Take 45-60 min to perform a 2 volume ExTx in a vigorous baby and longer in a sick one. If the infant is receiving O2 or assisted ventilation, measure pH, PaCO2 and PaO2 frequently (e.g., q 100 mL). You often will need to increase FIO2 during the ExTx. 3. Important reminders: Monitor ECG, blood pressure, O2 saturation, transcutaneous CO2 and temperature during ExTx. Measure pH at mid-point and at end of ExTx (more frequently in a sick baby. Measure glucose and electrolytes at end of ExTx, and glucose at 10, 30, 60 min later. Warm blood to 34-35 C. Warming blood to >37 C causes hemolysis. Agitate the unit of donor blood q 10-15 min so that cells do not settle. ExTx does not significantly plasma gentamicin level; do not give an extra dose. 4. Complications of ExTx: Problem with Effect on Donor Blood Infant Blood is cold High K+ Low pH (e.g., 6.9) Hypothermia Hyperkalemia, Arrhythmia Acidosis

Prevention or Treatment Warm donor blood to 34 - 35o C Use fresh blood, monitor ECG Consider buffering blood with THAM if infant is unstable. This will also [K+]. Consider platelet Tx at end of ExTx. If risk of bleeding, also Tx platelets at mid-point. Give 30 mg/kg of dilute Ca gluconate, over 5 min at , , and at end of a 2 volume ExTx, and if unexplained tachycardia or arrhythmia occurs. Start IV glucose at 5mg/kg/min 10-15 min after end of ExTx; monitor blood glucose.

No platelets (old Thrombocytopenia blood or PRBC+FFP) Citrate anticoagulant Low Ca++ & Mg++

High glucose

Reactive Hypoglycemia

Partial ExTx: To raise hematocrit in severe anemia: see section on Anemia (P. 108) and Hemolyic Disease of newborn (P. 121). To correct polycythemia: see section on Polycythemia/Hyperviscosity (P. 112).

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Copyright 2004 The Regents of the University of California